Consent Form to allow Third-parties access to GP Health records

This form to be used when patient would like to allow access to third parties ( including relatives , partners etc) to their GP health records.

Giving consent to someone else to communicate with us about you and your medical problems is a very significant step and you should give it serious consideration before you give consent. You need to consider what they might learn about you and your problems that you did not want them to know and have fully considered the ramifications of giving that consent. Once they learn information about you, they might also share it with others that you did not intend to have that information. If you are unsure about giving consent, we advise that you do not give it and that you seek legal advice before proceeding. Please complete all parts of this form including a current phone number.

Last Updated: 19/12/2024

Your Details

Patient Title *

Patients Full Name *

Patients Date of Birth *

Patients Current Mobile Number *

Patients Email Address *

I ALLOW PERMISSION TO *

MY PARTNER

MY DAUGHTER

MY SON

OTHER CLOSE RELATIVES

CARER

OTHER THIRD PARTIES

THIRD PARTY- FULL NAME *

THIRD PARTY - MOBILE AND LAND LINE NUMBER *

THIRD PARTY -EMAIL ADDRESS

PATIENT CONSENT -I consent allowing access to my confidential information from my GP medical record as stated in this form and to the person stated above *

Date *

SIGNATURE -Please write your full name *

DOES THE PATIENT CONSENT TO RECEIVE SMS/EMAIL ALERTS? *

Yes No

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION and details of third party you are submitting . THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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Consent Form to allow Third-parties access to GP Health records

Further Information